This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and
every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review
the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence
of Coverage (EOC), will prevail.
Anthem Blue Cross HMO benefits are covered only when services are provided or coordinated by the primary care physician and authorized
by the participating medical group or independent practice association (IPA), except services provided under the "ReadyAccess" program,
OB/GYN services received within the member's medical group/IPA, and services for all mental and nervous disorders and substance
abuse. Benefits are subject to all terms, conditions, limitations, and exclusions of the Policy.
Covered Medical Benefits
Cost if you use an
In-Network
Provider
Cost if you use a
Non-Network
Provider
Overall Deductible
See notes section to understand how your deductible works. Your plan may also have
a separate Prescription Drug Deductible. See Prescription Drug Coverage section.
$0 $0
Out-of-Pocket Limit
When you meet your out-of-pocket limit, you will no longer have to pay cost-shares
during the remainder of your benefit period. See notes section for additional
information regarding your out of pocket maximum.
$4,000 single /
$8,000 family
$0 single / $0 family
Doctor Home and Office Services
Preventive care/screening/immunization
In-network preventive care is not subject to deductible, if your plan has a
deductible.
No charge
Not covered
Primary care visit to treat an injury or illness
$25 copay per visit
Not covered
Specialist care visit
$40 copay per visit
Not covered
Prenatal and Post-natal Care
In network preventive pre natal and post natal services covered at 100%.
$25 copay per visit
Not covered
Other practitioner visits:
Page 2 of 9
Covered Medical Benefits
Cost if you use an
In-Network
Provider
Cost if you use a
Non-Network
Provider
Chiropractor services
Coverage for In-Network Provider is limited to 60 day limit per benefit
period for Physical, Occupational and Speech Therapy combined.
Chiropractor visits count towards your physical and occupational therapy
limit.
$25 copay per visit
Not covered
Acupuncture
$25 copay per visit
Not covered
Other services in an office:
Allergy testing
$25 copay per visit
Not covered
Chemo/radiation therapy
$40 copay per visit
Not covered
Hemodialysis
$40 copay per visit
Not covered
Prescription drugs
For the drugs itself dispensed in the office thru infusion/injection
30% coinsurance up
to $150 per visit
Not covered
Diagnostic Services
Lab:
Office
No charge
Not covered
Freestanding Lab
No charge
Not covered
Outpatient Hospital
20% coinsurance
Not covered
X-ray:
Office
No charge
Not covered
Freestanding Radiology Center
No charge
Not covered
Outpatient Hospital
20% coinsurance
Not covered
Advanced diagnostic imaging (for example, MRI/PET/CAT
scans):
Office
Costs may vary by site of service.
$100 copay per test
Not covered
Freestanding Radiology Center
Costs may vary by site of service.
$100 copay per test
Not covered
Outpatient Hospital
Provider
Provider
Emergency and Urgent Care
Emergency room facility services
This is for the hospital/facility charge only. The ER physician charge may be
separate. Copay waived if admitted.
$200 copay per visit
Covered as
In-Network.
Emergency room doctor and other services
No charge
Covered as
In-Network.
Ambulance (air and ground)
$100 copay per trip
for ground and air
Covered as In-
Network.
Urgent Care (office setting)
Copay waived if admitted. Costs may vary by site of service.
$25 copay per visit
Covered as
In-Network.
Outpatient Mental/Behavioral Health and Substance Abuse
Doctor office visit
$25 copay per visit
Not covered
Facility visit:
Facility fees
No charge
Not covered
Outpatient Surgery
Facility fees:
Hospital
20% coinsurance
Not covered
Freestanding Surgical Center
20% coinsurance
Not covered
Doctor and other services
No charge
Not covered
Hospital Stay (all inpatient stays including maternity, mental /
behavioral health, and substance abuse)
Facility fees (for example, room & board)
20% coinsurance
Not covered
Doctor and other services
No charge
Not covered
Recovery & Rehabilitation
Home health care
Coverage for In-Network Provider is limited to 100 visit limit per benefit
period.
Page 4 of 9
Covered Medical Benefits
Cost if you use an
In-Network
Provider
Cost if you use a
Non-Network
Provider
Rehabilitation services (for example,
physical/speech/occupational therapy):
Office
Coverage for In-Network Provider is limited to 60 day limit per benefit
period for Physical, Occupational and Speech Therapy combined. Costs may
vary by site of service. Chiropractor visits count towards your physical and
occupational therapy limit.
$25 copay per visit
Not covered
Outpatient hospital
Coverage for In-Network Provider is limited to 60 day limit per benefit
period for Physical, Occupational and Speech Therapy combined.
20% coinsurance
Not covered
Habilitation services
Habilitation visits count towards your rehabilitation limit.
20% coinsurance
Not covered
Cardiac rehabilitation
Office
Coverage for In-Network Provider is limited to 60 day limit per benefit
period for Physical, Occupational and Speech Therapy combined.
$25 copay per visit
Not covered
Outpatient hospital
Coverage for In-Network Provider is limited to 60 day limit per benefit
period for Physical, Occupational and Speech Therapy combined.
20% coinsurance
Not covered
Skilled nursing care (in a facility)
Coverage for In-Network Provider is limited to 100 day limit per benefit period.
20% coinsurance
Not covered
Hospice
No charge
Not covered
Durable Medical Equipment
50% coinsurance
Not covered
Covered Prescription Drug Benefits
Cost if you use an
In-Network
Provider
Cost if you use a
Non-Network
Provider
Pharmacy Deductible
$0
$0
Pharmacy Out of Pocket
$0 $0
Prescription Drug Coverage
This plan uses a National Drug List. Drugs not on the list are not covered.
Preventive Pharmacy
Preventive Immunization
$0 copay (retail
only)
50% coinsurance
(retail only)
Female oral contraceptive
Generic and Single Source brand
$0 copay (retail
only)
50% coinsurance
(retail only)
Tier1 - Typically Generic
Member pays the retail pharmacy copay plus 50% for out of network. Covers up
to a 30 day supply (retail pharmacy) Covers up to a 90 day supply (home
delivery program)
$10 copay per
prescription (retail
only) and $25 copay
per prescription
(home delivery only)
50% coinsurance
(retail and home
delivery)
Tier2 - Typically Preferred / Brand
Member pays the retail pharmacy copay plus 50% for out of network. Covers up
to a 30 day supply (retail pharmacy) Covers up to a 90 day supply (home
delivery program)
$30 copay per
prescription (retail
only) and $90 copay
per prescription
(home delivery only)
50% coinsurance
(retail and home
delivery)
Tier3 - Typically Non-Preferred / Specialty Drugs
Certain drugs require preauthorization approval to obtain coverage. Member
pays the retail pharmacy copay plus 50% for out of network. Covers up to a 30
day supply (retail pharmacy) Covers up to a 90 day supply (home delivery
program)
$45 copay per
prescription (retail
only) and $135
copay per
prescription (home
delivery only)
50% coinsurance
(retail and home
delivery)
Tier4 - Typically Specialty Drugs
Classified specialty drugs must be obtained through our Specialty Pharmacy
Program and are subject to the terms of the program. Member pays the retail
pharmacy copay plus 50% for out of network. Covers up to a 30 day supply
(retail pharmacy and home delivery program)
30% coinsurance up
to $250 per
prescription (retail
and home delivery)
50% coinsurance
(retail and home
delivery)
Page 6 of 9
Covered Prescription Drug Benefits
Cost if you use an
In-Network
Provider
Cost if you use a
Non-Network
Provider
Notes:
This Summary of Benefits has been updated to comply with federal and state requirements, including
applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance
and clarification on the new health care reform laws from the U.S. Department of Health and Human Services,
Department of Labor and Internal Revenue Service, we may be required to make additional changes to this
Summary of Benefits. This Summary of Benefits, as updated, is subject to the approval of the California
Department of Insurance and the California Department of Managed Health Care (as applicable).
In addition to the benefits described in this summary, coverage may include additional benefits, depending
upon the member's home state. The benefits provided in this summary are subject to federal and California
laws. There are some states that require more generous benefits be provided to their residents, even if the
master policy was not issued in their state. If the member's state has such requirements, we will adjust the
benefits to meet the requirements.
Your plan requires a selection of a Primary Care Physician. Your plan requires a referral from your Primary
Care Physician for select covered services.
Preventive Care Services includes physical exam, preventive screenings (including screenings for cancer, HPV,
diabetes, cholesterol, blood pressure, hearing and vision, immunization, health education, intervention services,
HIV testing) and additional preventive care for women provided for in the guidance supported by Health
Resources and Service Administration.
For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital,
reimbursement is based on the reasonable and customary value. Members may be responsible for any amount
in excess of the reasonable and customary value.
If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your
emergency room facility copay is waived.
Certain services are subject to the utilization review program. Before scheduling services, the member must
make sure utilization review is obtained. If utilization review is not obtained, benefits may be reduced or not
paid, according to the plan.
Additional visits maybe authorized if medically necessary. Pre-service review must be obtained prior to
receiving the additional services.
Skilled Nursing Facility day limit does not apply to mental health and substance abuse.
Respite Care limited to 5 visits per lifetime.
Freestanding Lab and Radiology Center is defined as services received in a non-hospital based facility.
Infertility services are not included in the out of pocket amount.
Coordination of Benefits: The benefits of this plan may be reduced if the member has any other group health
or dental coverage so that the services received from all group coverage do not exceed 100% of the covered
expense
When using non-network pharmacy; members are responsible for in-network pharmacy copay plus 50% of the
remaining prescription drug maximum allowed amount & costs in excess of the prescription drug maximum
allowed amount. Members will pay upfront and submit a claim form.
Preferred Generic Program: If a member requests a brand name drug when a generic drug version exists, the
member pays the generic drug copay plus the difference in cost between the prescription drug maximum
allowed amount for the generic drug and the brand name drug dispensed, but not more than 50% of our
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
Questions: (855) 333-5730 or visit us at
www.anthem.com/ca
CA/L/F/HMO/LH2077-SPH/LR2051/01-16
Page 8 of 9
physician has specified "dispense as written" (DAW) or when it has been determined that the brand name drug
is medically necessary for the member. In such case, the applicable copay for the dispensed drug will apply.
Supply limits for certain drugs may be different, go to Anthem website or call customer service.
For additional information on limitations and exclusions and other disclosure items that apply to this plan, go
to Anthem website or call customer service.
